FWA Training Attestation Form

Fraud, Waste and Abuse Training Attestation Form

Complete the following form (below). You can also print the form (). If you are printing the downloadable form, submit it by mail, fax or email.

Mail to:
Provider Relations
The Health Plan
52160 National Road East
St. Clairsville, OH 43950

Fax: 740.699.6169

Email: hpecs@healthplan.org

Please do not hesitate to contact our Provider Relations representatives for any assistance.

Fields listed with an "*" are required.

Mandatory *

Please check one *

I certify to the completion of the CMS Fraud, Waste and Abuse Training on CMS website
I certify to the completion of the required training on Fraud, Waste and Abuse Training

You must check one

For: *

Myself
Myself and Staff
All Providers in this group

Field not valid (required or bad value)

Name of organization providing alternate training *

Please type the organization's name providing alternate training

Completion Date *

Please enter a date of training completion

Entity, Facility, Group, Name or Vendor *

Please type entity's, facility's, group's, or vendor's name

Type of Organization * To select multiple items, hold down the Ctrl key and select items of interest

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Other Type of Organization If you checked Other, please name your type of organization

Completed By *

Please type your name

Title *

Please type your title or job occupation

Address *

Please include your Address

City *

Please include your city

State *

Please include your State

ZIP Code *

Please include your ZIP Code

Phone *

Please include your phone number. Do not include spaces

Email Please provide a valid email, if none exists, leave blank

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Provider NPI # *

Please type the Provider NPI number

Tax ID #

Please list Provider's name and/or staff's name who participated in this training:

You can use upper or lower case letters...

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